Computer-Aided Surgical Navigation Coding Guide Neurosurgery. May 1, 2009

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1 Computer-Aided Surgical Navigation Coding Guide Neurosurgery May 1, 2009 Please direct any questions to: Kim Brew Manager, Reimbursement and Therapy Access Medtronic Surgical Technologies (904)

2 TO OUR PARTNERS IN HEALTH CARE This document provides general reimbursement information provided to assist in obtaining coverage and reimbursement for healthcare services. These coding suggestions do not replace seeking coding advice from the payer and/or your own coding staff. The ultimate responsibility for correct coding lies with the provider of services. Please contact your local payer for interpretation of the appropriate codes to use for specific procedures. Medtronic makes no guarantee that the use of this information will prevent differences of opinion or disputes with Medicare or other third party payers as to the correct form of billing or the amount that will be paid to providers of service. All products should be used according to their labeling. Current Procedural Terminology (CPT) is copyright 2008 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT is a trademark of the American Medical Association. 1 All Current Procedural Terminology (CPT) five-digit numeric codes, descriptions, modifiers, instructions, guidelines, and other material are 2008 American Medical Association. 2

3 Physician Coding A Computer-Assisted Surgical Navigation System, also known as CASN or Stereotactic Guidance System, may be used for navigation around high-risk anatomical areas. CASN Procedure Code Physicians use CPT procedure codes to identify their services. There is one major CPT code for computer assisted surgical navigation in neurosurgical applications: Stereotactic computer assisted volumetric (navigational) procedure, intracranial, extracranial, or spinal Use of CPT Code When there is medical necessity, the use of a stereotactic guidance system may be reported in addition to the appropriate neurosurgical codes. Documentation should explain both the medical necessity and preplanning activities. Add-On Codes Code is an add-on code, as identified by the symbol, and must be reported in addition to the primary intracranial, extracranial, or spinal procedure. An add-on code: May not stand alone/be reported alone Must be performed in addition to a primary procedure Billing and Reimbursement for Code Medicare uses the Resource Based Relative Value Scale (RBRVS) fee schedule to reimburse physicians. Under RBRVS, each CPT code is assigned Relative Value Units (RVUs), similar to a weight, which is then converted to a standard payment amount. CPT RVU Facility Conv Factor Payment Description Stereotactic computer assisted volumetric (navigational) procedure, intracranial, extracranial, or spinal 6.47 $36.07 $ The RVUs and payment above apply only to the facility setting. CPT code has a Non-Facility NA Indicator on the National Physician Fee Schedule Relative Value File and is not billable in a non-facility setting. The global day indicator for code in the Federal Register is ZZZ, which means the code is related to a primary service and is included in the global period of the primary service. In other words, CPT code has no global period of its own and assumes the global days of the primary procedure. 3

4 Reimbursement is based only on the additional intra-operative service. Since CPT code is an addon code, it is valued only for the intra-operative service. There are no values for pre-operative or postoperative services, because is always assigned together with a primary procedure and creates only additional intra-operative services. Code has a multiple procedure indicator of 0, meaning that its payment is not reduced when it is billed with other procedures. It always pays at 100% of the RBRVS fee schedule amount. In other words, because it s always used with a primary procedure code, it has no values for approach and closure to reduce. Note that Medicare has assigned code a PC/TC (Professional Component/Technical Component) status of 0. This means that for Medicare billing, it is not necessary for physicians to use modifier 26 with because this code is already understood to represent the physician service. Separate Codes for Imaging with As defined, code is for computer-assisted navigation. Imaging is a component of the navigation. Whether imaging can be coded separately with CASN codes depends on the nature of the imaging performed and whether a separate formal imaging report is necessary. Imaging may be reported separately when full diagnostic imaging is performed. A separate formal imaging interpretation report should document that the imaging was necessary as a diagnostic service and not as a component of the CAS. Imaging should NOT be coded separately when fluoroscopic, CT and MR imaging is used solely for stereotactic localization of instruments relative to the anatomy and other computer-assisted guidance. The imaging should be considered integral to With the exception of intraoperative MRI, there are no NCCI edits which prohibit coding imaging with Therefore, when full diagnostic imaging is performed in addition to CASN, the imaging may be reported separately. A separate formal imaging report documenting the interpretation substantiates the imaging as a full diagnostic service rather than as a component of the CASN. Pre-Operative Scans The first scan is a coronal scan acquired for a gross overview of the patients anatomy, essentially a diagnostic scan that is ordinarily billable assuming formal interpretation is made with and a formal imaging report is generated. If the patient has diagnostic findings on the coronal scan and is a surgical candidate, a scan with much greater detail may be needed. If the second scan is taken for diagnostic purposes and a formal interpretation is made with generation of a formal imaging report, that substantiates separate coding and billing. However, if the second scan is taken only for the purpose of performing CAS and no formal report was generated, that would be considered integral and would not be separately coded or billed. 4

5 3D Reconstruction CASN procedures often involve 3D rendering of the images obtained. There are two CPT codes for 3D reconstruction. They are: CPT RVU Facility Conv Factor Payment Description 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image postprocessing on an independent workstation $36.07 $10.82 requiring imaging postprocessing on an independent workstation 1.16 $36.07 $41.84 It is important to note that if the 3D reconstruction is performed automatically as a function of the equipment, these codes cannot be used. However, use of these codes would be appropriate if the physician is directly involved in the 3D reconstruction. To use CPT the physician supervises a technician in creating the 3D images, interprets them and dictates a formal report. To use CPT the physician must also personally perform some of the adjustments needed to create the 3D images, interpret them and dictate a formal report. CASN versus Regular Guidance without Navigation The CASN codes by definition include computer-assisted navigation. This itself involves localization of the instruments relative to anatomy, either stereotactic or by use of dynamic referencing. Use of these codes rather than the CPT CASN code is appropriate when a surgeon uses images to understand anatomic positioning and localization during a procedure but is not using the images for surgical navigation. CPT has several codes for guidance for localization Fluoroscopic guidance for needle placement (eg. biopsy, aspiration, injection, localization device) CT guidance for stereotactic localization CT guidance for needle placement (eg. biopsy, aspiration, injection, localization device) MR guidance for needle placement (eg. biopsy, aspiration, injection, localization device) radiological supervision and interpretation. These codes cannot be billed with CPT If used with CPT CASN they must be considered clinically integral to the CASN procedure. 5

6 Hospital Coding Hospital Inpatient ICD-9-CM Procedure Codes for CASN ICD-9-CM has a series of codes for CASN Computer assisted surgery [CAS] CT-free navigation Image guided navigation (IGN) Image guided surgery (IGS) Imageless navigation Code also diagnostic or therapeutic procedure Excludes: stereotactic frame application only (93.59) Computer-assisted surgery with CT/CTA Computer-assisted surgery with MR/MRA Computer-assisted surgery with fluoroscopy Imageless computer-assisted surgery Computer-assisted surgery with multiple datasets Other computer-assisted surgery Use of ICD-9-CM Codes to The CASN ICD-9-CM procedure codes are always assigned in addition to the ICD-9-CM code for the primary procedure. As defined, the CAS codes are assigned according to the type of imaging used. The specific application is identified by the code for the primary procedure. What s Included with to The CASN ICD-9-CM codes include the use of imaging so additional codes for imaging are not used. Similarly, the CASN codes include the use of dynamic referencing or stereotactic frame application. Therefore, it s inappropriate to add for stereotactic head frame application. DRG Reimbursement Medicare uses Medicare Severity Diagnosis Related Groups (MS-DRGs) to reimburse hospitals for inpatient stays. The CASN ICD-9-CM codes are not designated as significant operating room procedures for DRG assignment. This means that the DRG is assigned according to the primary procedure code. The DRG payment for the primary procedure includes reimbursement for the use of CASN. 6

7 Although the CASN ICD-9-CM codes currently have no impact on DRG assignment, it is still essential to assign and submit the ICD-9-CM procedure codes for CAS with every procedure in which CAS was used. This is because CMS uses ICD-9-CM procedure code data to evaluate future DRG changes. Being able to identify CASN codes enables CMS to assess the impact of CASN on the relative cost of procedures and to potentially make adjustments in hospital inpatient reimbursement to compensate for the use of CASN. Hospital Outpatient CASN Procedure Code and Reimbursement Medicare considers code 61795, for stereotactic computer assisted volumetric navigational) procedure, intracranial, extracranial, or spinal, to be a packaged service. Status N indicates that payment for CASN is now included in the payment for the primary procedure, so no separate payment is made for Please contact your commercial payers for reimbursement information for CPT Separate Codes for Imaging with The imaging rules discussed in the previous Physician section also apply for hospital outpatient billing. Therefore, imaging may be reported separately when full diagnostic imaging is performed. A separate formal imaging interpretation report should document that the imaging was necessary as a diagnostic service, not as a component of the CAS. Medicare APCs for Radiology Codes Under APCs for Medicare, hospitals receive separate payment for the diagnostic Computerized Axial Tomography codes listed below in addition to the payment for the primary surgical procedure. Because these codes are status S, their payment is not reduced when multiple procedures are billed. CPT APC Description Computed tomography, head or brain; without Computed tomography, head or brain; with contrast material Computed tomography, head or brain; without, followed by (s) and further sections Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; with Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material, followed by (s) and further sections Computed tomography, maxillofacial area; without Computed tomography, maxillofacial area; with Computed tomography, maxillofacial area; without, followed by (s) and further sections Status Relative weight Payment S $ S $ S $ S $ S $ S $ S $ S $ S $

8 Computed tomography, soft tissue neck; without Computed tomography, soft tissue neck; with contrast material Computed tomography, soft tissue neck; with contrast material; without, followed by (s) and further sections Computed tomographic angiography, head, with (s), including noncontrast images, if performed, and image postprocessing Computed tomographic angiography, neck, with 0662 (s), including noncontrast images, if performed, and image postprocessing Magnetic resonance (eg, proton) imaging, orbit, face, 0336 and/or neck; without (s) Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; with (s) Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without (s), followed by (s) and further sequences Magnetic resonance angiography, head; without (s) Magnetic resonance angiography, head; with contrast material(s) Magnetic resonance angiography, head; without (s); followed by (s) and further sequences Magnetic resonance angiography, neck; without (s) Magnetic resonance angiography, neck; with contrast material(s) Magnetic resonance angiography, neck; without (s); followed by (s) and further sequences Magnetic resonance (eg, proton) imaging, brain (including brain stem); without Magnetic resonance imaging, brain (including brain stem) with contrast Magnetic resonance (eg, proton) imaging, brain (including brain stem); without followed by (s) and further sequences Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, requiring physician or psychologist administration Magnetic resonance (eg, proton) imaging, brain (including brain stem and skull base), during open intracranial procedure (eg, to assess for residual S $ S $ S $ S $ S $ S $ S $ S $ S $ S $ S $ S $ S $

9 tumor or residual vascular malformation); without Magnetic resonance (eg, proton) imaging, brain (including brain stem and skull base), during open intracranial procedure (eg, to assess for residual tumor or residual vascular malformation); with Magnetic resonance (eg, proton) imaging, brain (including brain stem and skull base), during open intracranial procedure (eg, to assess for residual tumor or residual vascular malformation); without followed by (s) and further sequences S $ S $ Medicare considers the 3D rendering codes and to be packaged services. Status N indicates that payment for 3D rendering is now included in the payment for the base imaging service, so no separate payment is made for these codes CPT APC Description Status Relative weight Payment NA 3D rendering w/o post processing N NA $ NA 3D rendering w/ post processing N NA $0 Please contact your commercial payers for reimbursement information for CPT and CPT Ambulatory Surgery Center Coding With some variations, Medicare s payment methodology for ASCs now mirrors the hospital outpatient reimbursement system. This generally includes using the same procedure code weights as those used for hospital outpatient. However, the conversion factor is lower for ASCs, resulting in ASC payment at about 65% of the hospital outpatient rates. In mirroring the hospital outpatient system, Medicare also adopted many of the same payment policies for ASCs, including the rules for packaged services. Services which are packaged and not separately payable in the hospital outpatient setting are also now packaged in the ASC setting. This eliminates separate payment for certain add-on codes that were previously payable in the ASC. Medicare s list of ASC Covered Surgical Procedures for CY 2009 includes only primary surgical procedures. However, Medicare also expanded the list of services payable in the ASC setting to include selected ancillary services designated as integral to covered surgical procedures. This includes many radiology codes which are eligible for separate payment in the ASC. CASN Procedure Code and Reimbursement Because the CASN code was packaged in the hospital outpatient setting, it was also packaged in the ASC setting. Medicare considers code 61795, for stereotactic computer assisted volumetric (navigational) procedure, intracranial, extracranial, or spinal, to be a packaged service. ASC status N1 indicates that payment for CASN is included in the payment for the primary procedure, so no separate payment is made for

10 Although other radiology codes are now separately payable, Medicare considers the 3D rendering codes and to be packaged services. ASC status N1 indicates that payment for 3D rendering is now included in the payment for the primary service, so no separate payment is made for these codes. CPT Description Status Relative weight Payment D rendering w/o post processing N1 $ D rendering w/ post processing N1 $0 Commercial Insurance Reimbursement for ASCs Please contact your commercial payers for reimbursement information for CPT Also, contact your commercial payors to insure that your contracted reimbursement arrangements reflect Medicare s newly expanded list of codes payable in the ASC. 10